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Putting Patients First: The Need to Reform Graduate Medical Education

In my January editorial, I called upon those responsible for graduate medical education (GME) to critically examine the design and conduct of their programs. I urged them to discover what changes are needed to ensure that residents are prepared to provide optimal care for the kinds of patients they will encounter most frequently when they enter practice. Four of the articles published in this month’s journal address issues relevant to the design and conduct of residency programs in family medicine (FM). I want to use several of the points made in the articles to emphasize the importance of the challenge I set forth in January. Let me be clear at the outset that my comments relate to residency training in FM only because FM is the focus of the papers appearing this month. I certainly don’t believe that GME programs in FM are more problematic than programs in other disciplines! Having said that, what can we learn from the articles in this month’s issue?

The papers by Kim and her colleagues and Sharp and Lipsky are particularly important. Kim and her colleagues report the results of a survey of graduates of programs affiliated with the University of Washington Family Practice Residency Network. The results of the survey show that a significant percentage of those trained in the network’s programs do not use the training they received in obstetrics in their practices, an observation consistent with national data collected by the American Academy of Family Practice. In addition, many of the practitioners who responded to the survey indicated that they had not been adequately prepared to perform certain procedures considered to be part of the usual scope of practice in FM. Along the same lines, Sharp and Lipsky report the results of a survey of family practice (FP) chief residents—individuals who were preparing to enter practice. The majority of the chief residents who responded to the survey indicated that they did not intend to include obstetrics in their future practices, and they also identified procedures that they felt ill prepared to perform.

Taken together, the articles suggest that residents in FM programs spend some of their time receiving training that is not relevant to their future practice plans (obstetrics training in this case), while at the same time receiving inadequate training in some areas deemed important for practice. The articles by Zweifler and Rodnick, which also appear in this month’s journal, provide some insight into the kinds of changes that might be considered to address this issue. Zweifler, a residency program director, suggests that the required duration of training in FM could be shortened to two years by eliminating some of the currently required experiences that are not really essential to the training of a family practitioner who plans to engage in the usual scope of FM practice. At least on the surface, his proposal would make training in FM in this country more similar to the training of family practitioners in Canada. In that country, FP residents who plan to engage in an expanded scope of practice take additional training as needed after completing the required two years of their residencies. Rodnick, a department chairman, suggests another approach. He describes certain features of the training of general practitioners in the United Kingdom that might be usefully adopted in this country. By putting forth these suggestions, Zweifler and Rodnick, both members of the academic FM community, acknowledge the need to consider some fundamental changes in the design and conduct of FM residency programs in this country.

The general observations reported in this month’s articles are not unique to residency training in FM. In recent years, a number of surveys have been conducted to gain insight into how well practicing physicians believe they were prepared for practice in their disciplines. In all of the surveys, many of the respondents identified deficiencies in their training—aspects of the scope of their practice that they were not well prepared for. And almost all noted that they were trained to provide certain kinds of care that were not part of their eventual scope of practice. It seems clear, therefore, that there is a mismatch of varying degrees across the specialties between the design and conduct of the training provided by residency programs and the scope of practice that graduates of the programs will be responsible for on entering practice. This is the issue that I believe those responsible for GME must address.

I am not alone in thinking that this is an important issue, nor am I the first to point out the need to address it. Note what four experienced clinicians and educators have previously had to say about this.

There can be no change in the direction of medicine without a concurrent change in the training of doctors so that their education matches them to their actual tasks in the care of patients. - Eric Cassell, MD, Cornell University (1995)1

Routinely assigning residents on the basis of the floors and units that need to be covered, and requiring residents to be involved in the care of all patients no matter how skewed the hospital or clinic census happens to be, cannot help but distort the educational program. And it clearly takes time away from other, potentially more valuable educational activities. - Jordan Cohen, MD, President, Association of American Medical Colleges (AAMC) (1998)2

A major disadvantage of the current residency system is that the time required for training in each specialty was, in the past, arbitrarily chosen based on the opinions of those doing the training. Little attention was paid to the actual time required to learn a particular procedure or fully understand how to treat a particular condition. - Don Long, MD, Johns Hopkins University School of Medicine (2000)3

It is time for all medical and surgical fields to revisit outdated paradigms of the generalist, specialist, and subspecialist physician and to revise training programs in light of new realities. - Michael Johns, MD, Emory University (2001)4

If experienced clinician educators have been calling attention to this issue for a number of years, why does the situation persist? Quite simply, because residency programs must conform for accreditation purposes to the Program Requirements adopted by the ACGME Residency Review Committees (RRCs). And to varying degrees, the requirements developed by the RRCs reflect a somewhat idealized concept of the kind of training residents require rather than the kind of training needed to truly prepare them for the current practice of medicine. To do the latter, the deliberations of an RRC about the program requirements in its discipline would have to be informed by an analysis of contemporary practice in that discipline. Unfortunately, this kind of information is not readily available in most of the clinical specialties.

To their credit, the members of the FM community have embarked on an approach for addressing this issue that can serve as a model for other specialties. Several years ago, a group of leaders in the discipline (the Family Practice Working Group) concluded that it was time for the FM community at large to “take stock of the present and grapple with the future of the discipline of FM.” In response, all of the major academic FM organizations agreed to participate in a project—the Future of Family Medicine (FFM) Project—designed for that purpose.

The charge of the FFM Project is to “develop a strategy to transform and renew the specialty of FP to meet the needs of people and society in a changing environment.” The leaders of the project engaged a national consulting firm to conduct survey research to determine the role that family physicians could or should play in the health care system. There are five task forces at work collecting information that will help the project leaders decide how to respond to the project charge. Several of the task forces are addressing specific issues that will allow the project leadership to determine the knowledge, skills, and attitudes that future family physicians will need to practice the discipline. Those determinations will presumably guide the development of recommendations for changes in the design and conduct of FM residency programs in this country.

Regardless of how they may go about it, those responsible for the design and conduct of GME programs in all of the clinical specialties should focus their attention on determining the kind of training that residents need to care for patients when they enter practice, not the kind of training those in the field believe to be important for reasons having to do more with the tradition and culture of the specialty and the service needs of teaching hospitals and their clinical faculties. As they consider making needed changes in GME, their goal should be clear—to put the needs of patients first! It is clearly time to begin to reform GME so that this goal can be achieved.

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